This research proposal will investigate the impact on resource utilization and patient outcomes of Critical Pathway guidelines that are implemented within a framework of continuous quality improvement (CQI). In addition, in order to learn about the process of CQI itself, the study will trace the types and sequence of change processes of clinical care, from those made initially during Critical Pathway development to those made subsequently after clinicians receive feedback on """"""""variances"""""""" from the Critical Pathways. Critical Pathways are a new format of clinical guideline that display a prescribed sequence and timing of multidisciplinary staff actions to achieve maximal quality and efficiency of care. Critical Pathway initiatives are currently being launched around the United States, but serious deficiencies in knowledge about their effectiveness exist: no controlled study has been able to demonstrate a reduction in length of stay or resource use; no study has found an improvement in patient satisfaction or outcomes. In addition, no description has been published of the types of clinical process changes that are being incorporated into Critical Pathways in the effort to improve efficiency, nor have reports evaluated the process of CQI by tracing the sequence of any subsequent clinical process changes made after the feedback of variance data to clinicians has begun. The proposed research will address these deficiencies in a study of approximately 8,000 patients hospitalized with one of five diagnoses: Normal Vaginal Delivery, Total Knee Replacement, Craniotomy, Deep Vein Thrombosis, and Chest Pain. Planned analyses will track the sequence, of clinical process changes and will compare patient satisfaction, clinical outcomes, and resource utilization data during two phases: 1) a baseline, pre-Critical Pathway period; and 2) an intervention period during which the Critical Pathway will be implemented and feedback delivered to clinicians of variance and outcomes data. Historical controls for each diagnosis will be bolstered by comparing changes in length of stay and resource utilization with changes seen at comparable area hospitals for the same diagnoses and with secular trends in control diagnoses at our institution or which Critical Pathways will not be implemented.
The specific aims of the project are: 1) To assess the effect of Critical Pathways on length of stay, resource utilization during and after hospitalization, patient satisfaction with care, and patient outcomes following discharge; and 2) To evaluate the importance of the feedback of variance data as part of a CQI program by describing the types and sequence of process changes that are created at different stages along the cycle of Critical Pathway development, implementation, and clinician review of feedback data.
